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CENTRAL NERVOUS SYSTEM INFECTIONS
CONTENTS
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Anatomy
The central nervous system (CNS) is comprised of the brain and spinal cord. The CNS receives sensory information from the nervous system and controls the body's responses. The CNS is differentiated from the peripheral nervous system, which involves all the nerves outside of the brain and spinal cord that carry messages to the CNS.
The central nervous system plays a primary role in receiving information from various areas of the body and then coordinating this activity to produce the body's responses.
CENTRAL NERVOUS SYSTEM ANATOMY
The CNS has three main components: the brain, the spinal cord, and the neurons (or nerve cells).
The Brain
The brain controls many of the body's functions including sensation, thought, movement, awareness, and memory. The surface of the brain is known as the cerebral cortex. The surface of the cortex appears bumpy thanks to the grooves and folds of the tissue. Each groove is known as a sulcus, while each bump is known as a gyrus.
The largest part of the brain is known as the cerebrum and is responsible for things such as memory, speech, voluntary behaviors, and thought.
The cerebrum is divided into two hemispheres, a right hemisphere, and a left hemisphere. The brain's right hemisphere controls movements on the body's left side, while the left hemisphere controls movements on the body's right side.
While some functions do tend to be lateralized, researchers have found that there are not "left-brained" or "right-brained" thinkers, as the old myth implies. Both sides of the brain work together to produce various functions.
Each hemisphere of the brain is then divided into four interconnected lobes:
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Frontal lobes are associated with higher cognition, voluntary movements, and language.
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Occipital lobes are associated with visual processes.
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Parietal lobes are associated with processing sensory information.
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Temporal lobes are associated with hearing and interpreting sounds as well as the formation of memories.
Spinal Cord
The spinal cord connects to the brain via the brain stem and then runs down through the spinal canal, located inside the vertebra. The spinal cord carries information from various parts of the body to and from the brain. In the case of some reflex movements, responses are controlled by spinal pathways without involvement from the brain.
Neurons
Neurons are the building blocks of the central nervous system. Billions of these nerve cells can be found throughout the body and communicate with one another to produces physical responses and actions.
Protective Structures
Since the CNS is so important, it is protected by several structures. First, the entire CNS is enclosed in the bone. The brain is protected by the skull, while the spinal cord is protected by the vertebra of the spinal column. The brain and spinal cord are both covered with a protective tissue known as meninges.
Neurons are the body's information superhighway. An estimated 86 billion neurons can be found in the brain alone.
The entire CNS is also immersed in a substance known as cerebrospinal fluid, which forms a chemical environment to allow nerve fibers to transmit information effectively as well as offering yet another layer of protection from potential damage.
The central nervous system may be infected by various agents, including viruses, bacteria, fungi, protozoa, and helminths. In addition, numerous noninfectious etiologies may account for syndromes that mimic CNS infections. These include neoplastic diseases, intracranial tumors and cysts, medications, collagen vascular disorders, autoimmune disorders, and other systemic illnesses and conditions arising after various procedures that invade the central nervous system.
The clinical presentation of a CNS infection may be acute, subacute, or chronic, depending on the virulence of the infecting agent and the location of the infection.
Because CNS infections occur within the confines of the cranium or spinal column, they may be associated with significant morbidity and mortality, often necessitating emergent interventions to improve outcomes.
Infections of the nervous system are potentially life-threatening and are caused by pathogens such as bacteria, viruses, and fungi. Prompt recognition and treatment of a central nervous system (CNS) infection are crucial for patient survival, as these infections have high morbidity and mortality.
TYPES OF INFECTIONS
CNS infections include meningitis, encephalitis, and brain abscesses.
MENINGITIS
OVERVIEW
Meningitis is an inflammation of the meninges. The meninges are the three membranes that cover the brain and spinal cord. Meningitis can occur when fluid surrounding the meninges becomes infected.
The most common causes of meningitis are viral and bacterial infections. Other causes may include:
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cancer
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chemical irritation
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fungi
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drug allergies
Some viral and bacterial meningitis are contagious. They can be transmitted by coughing, sneezing, or close contact.
SYMPTOMS OF MENINGITIS
The symptoms of viral and bacterial meningitis can be similar in the beginning. However, bacterial meningitis symptoms are usually more severe. The symptoms also vary depending on your age.
Viral meningitis symptoms
In adults, viral meningitis may cause:
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headaches
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fever
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stiff neck
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seizures
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sensitivity to bright light
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sleepiness
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lethargy
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nausea and vomiting
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decreased appetite
Bacterial meningitis symptoms
Bacterial meningitis symptoms develop suddenly. They may include:
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altered mental status
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nausea
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vomiting
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sensitivity to light
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irritability
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headache
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fever
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chills
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stiff neck
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purple areas of skin that resemble bruises
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sleepiness
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lethargy
Seek immediate medical attention if you experience these symptoms. Bacterial and viral meningitis can be deadly. There is no way to know if you have bacterial or viral meningitis just by judging how you feel. Our specialists will need to perform tests to determine which type you have.
Fungal meningitis symptoms
Symptoms of fungal meningitis resemble the other types of this infection. These may include:
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nausea
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vomiting
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sensitivity to light
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fever
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headache
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confusion or disorientation
TYPES OF MENINGITIS
Viral and bacterial infections are the most common causes of meningitis. There are several other forms of meningitis. Examples include cryptococcal, which is caused by a fungal infection, and carcinomatous, which is cancer-related. These types are less common.
Viral meningitis
Viral meningitis is the most common type of meningitis. Viruses in the Enterovirus category cause 85 percent of cases. These are more common during the summer and fall, and they include:
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coxsackievirus A
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coxsackievirus B
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echoviruses
Viruses in the Enterovirus category cause about 10 to 15 million infections per year, but only a small percentage of people who get infected will develop meningitis.
Other viruses can cause meningitis. These include:
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West Nile virus
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influenza
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mumps
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HIV
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measles
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herpes viruses
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Coltivirus, which causes Colorado tick fever
Viral meningitis typically goes away without treatment. However, some causes do need to be treated.
Bacterial Meningitis
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Streptococcus pneumoniae, which is typically found in the respiratory tract, sinuses, and nasal cavity and can cause what is called “pneumococcal meningitis”
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Neisseria meningitidis, which is spread through saliva and other respiratory fluids and causes what is called “meningococcal meningitis”
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Haemophilus influenza, which can cause not only meningitis but infection of the blood, inflammation of the windpipe, cellulitis, and infectious arthritis
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Listeria monocytogenes, which are foodborne bacteria.
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Staphylococcus aureus, which is typically found on the skin and in the respiratory tract, and causes “staphylococcal meningitis.”
Bacterial meningitis is contagious and caused by infection from certain bacteria. It is fatal if left untreated. Between children and adults with this condition die. This is true even with proper treatment.
The most common types of bacteria that cause bacterial meningitis are:
Fungal meningitis
Fungal meningitis is a rare type of meningitis. It is caused by a fungus that infects your body and then spreads from your bloodstream to your brain or spinal cord.
People with a weakened immune system are more likely to develop fungal meningitis. This includes people with cancer or HIV.
The most common funguses related to fungal meningitis include:
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Cryptococcus, which is inhaled from dirt or soil that is contaminated with bird droppings.
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Blastomyces, another type of fungus found in soil, particularly in the Midwestern United States
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Histoplasma, which is found in environments that are heavily contaminated with bat and bird droppings, especially in the Midwestern States near the Ohio and Mississippi Rivers
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Coccidioides, which is found in soil in specific areas of the U.S. Southwest and South and Central America
Parasitic meningitis
This type of meningitis is less common than viral or bacterial meningitis, and it is caused by parasites that are found in dirt, feces, and on some animals and food, like snails, raw fish, poultry, or produce.
One type of parasitic meningitis is rarer than others. It is called eosinophilic meningitis (EM). Three main parasites are responsible for EM. These include:
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Angiostrongylus cantonensis
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Baylisascaris procyonis
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Gnathostoma spinigerum
Parasitic meningitis is not passed from person to person. Instead, these parasites infect an animal or hide out on food that a human then eats. If the parasite or parasite eggs are infectious when they are ingested, an infection may occur.
One exceedingly rare type of parasitic meningitis, amebic meningitis, is a life-threatening type of infection. This type is caused when one of several types of ameba enters the body through the nose while you swim in contaminated lakes, rivers, or ponds. The parasite can destroy brain tissue and may eventually cause hallucinations, seizures, and other serious symptoms. The most recognized species is Naegleria fowleri.
Non-infectious meningitis
Non-infectious meningitis is not an infection. Instead, it is a type of meningitis that is caused by other medical conditions or treatments. These include:
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a head injury
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brain surgery
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cancer
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certain medications
CAUSES OF MENINGITIS
Each type of meningitis has a slightly different cause, but each behaves in the same way: A bacterium, fungus, virus, or parasite spreads through the bloodstream until it reaches the brain or spinal cord. There, it sets up in the lining or fluids around these vital body parts and starts developing into a more advanced infection.
Non-infectious meningitis is the result of a physical injury or other condition; it does not involve an infection.
IS THERE A VACCINE FOR MENINGITIS?
Yes, there is a vaccine for several types of bacterial meningitis. Meningococcal meningitis, caused by Neisseria meningitides, is one version for which vaccines are available. While viral meningitis is more common, bacterial meningitis can be more dangerous if it is not diagnosed and treated quickly.
For that reason, the two primary vaccines for meningitis are for bacterial causes. The first vaccine, the meningococcal conjugate vaccine, features a vaccine that targets four of the most common types of bacterial serotypes. It lasts longer and offers greater protection, especially if you maintain booster shots.
The second vaccine, MenB, targets one specific strain, and its protection window is much shorter. Only certain populations are recommended to get this vaccine.
Side effects of a meningitis vaccine include soreness, redness, and burning at the injection site. Some people may experience a low-grade fever for a day or two following the injection. Chills, headache, joint pain, and fatigue are also possible.
HOW CONTAGIOUS IS MENINGITIS?
Several types of meningitis are not contagious. Fungal, parasitic, and non-infectious meningitis is not contagious.
Viral meningitis is contagious. It is spread through direct contact with body fluids, including mucus, feces, and saliva. Droplets of infected fluid can be spread and shared with sneezing and coughing. You do not have to come into direct contact with an infected person to pick up this infection.
Bacterial meningitis, the most serious form of meningitis, can also be contagious, especially if it is meningococcal meningitis. It is spread through extended contact with an infected person. Schools, daycare centers, military barracks, hospitals, and college dormitories are prime locations for sharing this infection. Some types of meningitis are spread through person-to-person contact but not all.
DIAGNOSING MENINGITIS
Diagnosing meningitis starts with a health history and physical exam. Age, dorm residence, and day care center attendance can be important clues. During the physical exam, our specialists will look for:
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a fever
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an increased heart rate
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neck stiffness
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reduced consciousness
Our specialists will also order a lumbar puncture. This test is also called a spinal tap. It allows your doctor to look for increased pressure in the central nervous system. It can also find inflammation or bacteria in the spinal fluid. This test can also determine the best antibiotic for treatment.
Other tests may also be ordered to diagnose meningitis. Common tests include the following:
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Blood cultures identify bacteria in the blood. Bacteria can travel from the blood to the brain. N. meningitidis and S. pneumonia, among others, can cause both sepsis and meningitis.
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A complete blood count with differential is a general index of health. It checks the number of red and white blood cells in your blood. White blood cells fight infection. The count is usually elevated in meningitis.
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Chest X-rays can reveal the presence of pneumonia, tuberculosis, or fungal infections. Meningitis can occur after pneumonia.
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A CT scan of the head may show problems like a brain abscess or sinusitis. Bacteria can spread from the sinuses to the meninges.
TREATMENT OF MENINGITIS
Your treatment is determined by the cause of your meningitis.
Bacterial meningitis requires immediate hospitalization. Early diagnosis and treatment will prevent brain damage and death. Bacterial meningitis is treated with intravenous antibiotics. There is no specific antibiotic for bacterial meningitis. It depends on the bacteria involved.
Fungal meningitis is treated with antifungal agents.
Parasitic meningitis may either involve treating just the symptoms or attempting to treat the infection directly. Depending on the cause, this type may get better without antibiotic treatment. If it worsens, however, our specialists may try to treat the infection itself.
Viral meningitis may resolve on its own, but some causes of viral meningitis will be treated with intravenous antiviral medications.
MENINGITIS PREVENTION
Maintaining a healthy lifestyle, especially if you are at increased risk, is important. This includes:
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getting adequate amounts of rest
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not smoking
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avoiding contact with sick people
If you have been in close contact with one or more people who have a bacterial meningococcal infection, your doctor can give you preventive antibiotics. This will decrease your chances of developing the disease.
Vaccinations can also protect against certain types of meningitis. Vaccines that can prevent meningitis include the following:
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Haemophilus influenzae type B (Hib) vaccine
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pneumococcal conjugate vaccine
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meningococcal vaccine
Practicing good personal hygiene may also help you prevent meningitis. Some types of meningitis are spread through close contact with an infected person’s body fluid, such as saliva and nasal secretions. Avoid sharing drinks, utensils, and personal items that may carry saliva or other fluids.
ENCEPHALITIS
WHAT IS ENCEPHALITIS?
Encephalitis is an inflammation of the brain tissue. The most common cause is viral infections. In rare cases, it can be caused by bacteria or even fungi.
There are two main types of encephalitis: primary and secondary. Primary encephalitis occurs when a virus directly infects the brain and spinal cord. Secondary encephalitis occurs when an infection starts elsewhere in the body and then travels to your brain.
Encephalitis is a rare yet serious disease that can be life-threatening. You should call your doctor immediately if you have symptoms of encephalitis.
SYMPTOMS OF ENCEPHALITIS
The symptoms of encephalitis can range from mild to severe.
Mild symptoms include:
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fever
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headache
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vomiting
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stiff neck
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lethargy (exhaustion)
Severe symptoms include:
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fever of 103°F (39.4°C) or higher
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confusion
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drowsiness
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hallucinations
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slower movements
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coma
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seizures
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irritability
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sensitivity to light
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unconsciousness
Infants and young children show different symptoms. Call a doctor immediately if your child is experiencing any of the following:
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vomiting
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bulging fontanel (soft spot in the scalp)
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constant crying
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body stiffness
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poor appetite
TYPES OF ENCEPHALITIS
There are two main types of encephalitis:
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Primary encephalitis. This condition occurs when a virus or other agent directly infects the brain. The infection may be concentrated in one area or widespread. A primary infection may be a reactivation of a virus that had been inactive after a previous illness.
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Secondary encephalitis. This condition results from a faulty immune system reaction to an infection elsewhere in the body. Instead of attacking only the cells causing the infection, the immune system also mistakenly attacks healthy cells in the brain. Also known as post-infection encephalitis, secondary encephalitis often occurs two to three weeks after the initial infection.
WHAT CAUSES ENCEPHALITIS?
The exact cause of encephalitis is often unknown. But when a cause is known, the most common is a viral infection. Bacterial infections and noninfectious inflammatory conditions also can cause encephalitis.
Up to 60% of encephalitis cases result from an unidentified etiologic agent.
Common viral causes
The viruses that can cause encephalitis include:
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Herpes simplex virus (HSV). Both HSV type 1 — associated with cold sores and fever blisters around your mouth — and HSV type 2 — associated with genital herpes — can cause encephalitis. Encephalitis caused by HSV type 1 is rare but can result in significant brain damage or death.
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Other herpes viruses. These include the Epstein-Barr virus, which commonly causes infectious mononucleosis, and the varicella-zoster virus, which commonly causes chickenpox and shingles.
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Enteroviruses. These viruses include the poliovirus and the coxsackievirus, which usually cause an illness with flu-like symptoms, eye inflammation, and abdominal pain.
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Mosquito-borne viruses. These viruses can cause infections such as West Nile, La Crosse, St. Louis, western equine and eastern equine encephalitis. Symptoms of an infection might appear within a few days to a couple of weeks after exposure to a mosquito-borne virus.
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Tick-borne viruses. The Powassan virus is carried by ticks and causes encephalitis in the Midwestern United States. Symptoms usually appear around a week after a bite from an infected tick.
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Rabies virus. Infection with the rabies virus, which is usually transmitted by a bite from an infected animal, causes a rapid progression to encephalitis once symptoms begin. Rabies is a rare cause of encephalitis in the United States.
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Childhood infections. Common childhood infections — such as measles (rubeola), mumps, and German measles (rubella) — used to be common causes of secondary encephalitis. These causes are now rare in the United States due to the availability of vaccinations for these diseases.
WHAT ARE THE RISKS OF ENCEPHALITIS?
The groups most at risk of encephalitis are:
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older adults
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children under the age of 1
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people with weak immune systems
You may also have a higher risk of getting encephalitis if you live in an area where mosquitos or ticks are common. Mosquitos and ticks can carry viruses that cause encephalitis. You are more likely to get encephalitis in the summer or fall when these insects are most active.
Although the MMR (measles, mumps, rubella) vaccine has a long history of being safe and effective, in rare cases it has caused encephalitis. 1 in 3 million children (about the population of Arkansas) who receive the vaccine develop encephalitis. However, the statistics are much more striking for children who do not receive the vaccine. Rates of encephalitis in the days before routine vaccination reached as high as 1 in 1,000. In other words, encephalitis was 3,000 times more common before vaccination was available.
DIAGNOSING ENCEPHALITIS
Our board-certified specialists will first ask you about your symptoms. They may perform the following tests if encephalitis is suspected.
Spinal tap or lumbar puncture
In this procedure, your doctor will insert a needle into your lower back to collect a sample of spinal fluid. They will test the sample for signs of infection.
Brain imaging with CT scan or MRI
CT scans and MRI detect changes in brain structure. They can rule out other explanations for symptoms, such as a tumor or stroke. Certain viruses tend to affect certain areas of the brain. Seeing what parts of your brain are affected can help determine what type of virus you have.
Electroencephalograph (EEG)
An EEG uses electrodes (small metal discs with wires) attached to the scalp to record brain activity. An EEG does not detect the virus that causes encephalitis, but certain patterns on the EEG may alert your neurologist to an infectious source of your symptoms. Encephalitis can lead to seizures and coma in later stages. That is why the EEG is important in determining the areas of the brain that are affected and the types of brain waves that occur in each area.
Blood tests
A blood test can reveal signs of a viral infection. Blood tests are rarely performed alone. They usually help diagnose encephalitis along with other tests.
Brain biopsy
In a brain biopsy, your doctor will remove small samples of brain tissue to test for infection. This procedure is rarely performed because there is an elevated risk of complications. It has usually only done if doctors cannot determine the cause of the brain swelling or if treatment is not working.
HOW IS ENCEPHALITIS TREATED?
Anti-viral medications can help treat herpes encephalitis. However, they are not effective in treating other forms of encephalitis. Instead, treatment often focuses on relieving symptoms. These treatments may include:
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rest
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pain killers
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corticosteroids (to reduce brain inflammation)
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mechanical ventilation (to help with breathing)
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lukewarm sponge baths
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anticonvulsants (to prevent or stop seizures)
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sedatives (for restlessness, aggressiveness, and irritability)
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fluids (sometimes through an IV)
You may need to be hospitalized during treatment, especially with brain swelling and seizures.
COMPLICATIONS
Most people who are diagnosed with severe encephalitis will experience complications. Complications resulting from encephalitis can include:
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loss of memory
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behavioral/personality changes
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epilepsy
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fatigue
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physical weakness
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intellectual disability
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lack of muscle coordination
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vision problems
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hearing problems
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speaking issues
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coma
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difficulty breathing
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death
Complications are more likely to develop in certain groups, such as:
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older adults
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people who have had coma-like symptoms.
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people who did not get treatment right away
LONG TERM OUTLOOK
Your outlook will depend on the severity of the inflammation. In mild cases of encephalitis, the inflammation will resolve in a few days. For people who have severe cases, it may require weeks or months to get better. It can sometimes cause permanent brain damage or even death.
People with encephalitis may also experience:
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loss of brain function
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problems with speech, behavior, memory, and balance
Depending on the type and severity of encephalitis, it may be necessary to receive additional therapy, including:
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physical therapy: to improve strength, coordination, balance, and flexibility
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occupational therapy: to help redevelop everyday skills
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speech therapy: to help relearn muscle control needed for talking
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psychotherapy: to help with coping strategies, mood disorders, or personality changes
CAN ENCEPHALITIS BE PREVENTED?
Encephalitis is not always preventable, but you can lower your risk by getting vaccinated for viruses that can cause encephalitis. Also, make sure your children receive vaccinations for these viruses. In areas where mosquitos and ticks are common, use repellants, and wear long sleeves and pants. If you are traveling to an area that is known for viruses that cause encephalitis, please call us for vaccination recommendations.
BRAIN ABSCESSES
OVERVIEW
Brain abscesses of an otherwise healthy person are a focal, intracerebral infection that begins as a localized area of cerebritis then develop into collections of pus surrounded by well-vascularized capsules that cause the brain to swell and are usually caused by bacterial infections.
Fungal brain abscesses tend to occur in people with weakened immune systems.
A brain abscess forms when fungi, viruses, or bacteria reach your brain through a wound in your head or an infection somewhere else in your body. Infections from other parts of the body account for between 20 and 50 percent of all brain abscess cases. Heart and lung infections are among the most common causes of brain abscesses. However, brain abscesses can also begin from an ear or sinus infection, or even an abscessed tooth.
Call our office right away if you think you may have a brain abscess. You will need the appropriate treatment to prevent any brain damage from the swelling.
WHAT ARE THE RISK FACTORS?
Anyone can get a brain abscess, but certain groups of people are at a higher risk than others. Some diseases, disorders, and conditions that raise your risk include:
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a compromised immune system due to HIV or AIDS
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cancer and other chronic illnesses
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Congenital heart disease
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major head injury or skull fracture
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Meningitis
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Immunosuppressant drugs, such as those used in chemotherapy.
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chronic sinus or middle ear infections
Certain birth defects allow infections to reach the brain more easily through the teeth and intestines. One example of this is the tetralogy of Fallot, which is a heart defect.
SYMPTOMS OF BRAIN ABSCESSES
Symptoms usually develop slowly over several weeks, but they can also come on suddenly. Symptoms you should watch for are:
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differences in mental processes, such as increased confusion, decreased responsiveness, and irritability
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decreased speech
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decreased sensation
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decreased movement due to loss of muscle function
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changes in vision
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changes in personality or behavior
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vomiting
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fever
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chills
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neck stiffness, especially when it occurs with fevers and chills
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sensitivity to light
DIAGNOSING A BRAIN ABSCESS
Many of these symptoms closely resemble other diseases or health problems. Please call our office immediately if you develop any of the symptoms. You will need a neurological exam. This exam can reveal any increased pressure within the brain, which can occur from swelling. CT and MRI scans can also be used to diagnose a brain abscess.
In some cases, our specialists may need to perform a lumbar puncture or spinal tap. This involves the removal of a small amount of cerebral spinal fluid to test for any problems other than an infection. A lumbar puncture will not be performed if any significant brain swelling is suspected, as it can temporarily worsen the pressure inside the head. This is to avoid the risk of brain hematoma, or a ruptured blood vessel in the brain.
TREATMENT OF BRAIN ABSCESSES
A brain abscess is a serious medical situation. A stay in the hospital will be required. Pressure due to swelling in the brain can lead to permanent brain damage.
If your abscess is deep inside your brain or it is 2.5 centimeters or less, it will be treated with antibiotics. Antibiotic medications will also be used to
treat any underlying infections that may have been the cause of the brain abscess. Broad-spectrum antibiotics that kill a variety of different bacteria are the most prescribed. You may need more than one type of antibiotic.
Surgery is often the next step if an abscess does not get smaller with the use of antibiotics. It may also be the preferred treatment for abscesses greater than 2.5 centimeters wide. Surgically removing an abscess usually involves opening the skull and draining the abscess. The fluid that is removed is normally sent to a lab to determine the cause of the infection. Knowing the cause of the infection will help your doctor find the most effective antibiotics. Surgery may also be necessary if antibiotics are not working so that the organism causing the abscess can be determined to help guide the most effective treatment.
Surgery must be performed in the most severe cases when the abscess causes a dangerous buildup of pressure in the brain. Your doctor may recommend surgery as the best option in the following cases:
Your brain abscess is at risk of rupturing inside of your skull.
Your brain abscess contains gasses sometimes produced by bacteria.
CAN A BRAIN ABSCESS BE PREVENTED?
A brain abscess is a serious medical condition. Prevention is important. You can lower your risk by monitoring any conditions that can cause a brain abscess. Call our office at the first sign of a brain abscess.
If you have any type of heart disorder, talk with our specialists before having any dental or urological procedures. Our specialists can prescribe antibiotics for you to take before these procedures. This will reduce your risk of an infection that could spread to your brain.